Maggie McKay (Host): Welcome to the Live Greater podcast series, information for a Healthier You from the University of Maryland Medical System. I'm your host, Maggie McKay. Joining us today is Lindsay Goff, Primary Stroke Program Coordinator at University of Maryland Upper Chesapeake Health, to discuss what patients need to know about migraine, PFO, and stroke. Thank you so much for being here today, Lindsay.

Lindsay Goff, BSN, RN, NRP: Thank you for having me.

Host: Let's start with what is a PFO.

Lindsay Goff, BSN, RN, NRP: So, PFO is the literal medical term. It is called a patent foramen ovale. It's a hole in your heart that is supposed to close in the first year after birth. We do see this in ischemic stroke patients. That can be a cause of stroke. But also, the correlation with this whole not closing, it also has a strong correlation with migraines, which is why we're here today.

Host: What is the incidence of stroke in certain populations who have migraines?

Lindsay Goff, BSN, RN, NRP: So, stroke in certain populations, migraine patients, it varies. So, the biggest correlation between PFOs, migraines, and stroke is that migraines with an aura can mimic strokes. And when we're looking at the causes of these strokes, specifically ischemic strokes caused by a clot bstructing blood flow, a PFO is one of the things that we do look for. And we see this in, you know, 20-40% of Caucasian women that have migraines, which means they have a PFO. And that incidence is pretty low in ischemic stroke, but it is a risk factor.

Host: And you touched on this a little bit, but could you explain what is the possible connection between migraine, especially migraine with aura and PFO?

Lindsay Goff, BSN, RN, NRP: Yes. So, migraine with aura—so there's two different types that we look at in neurology. A migraine without aura, so this is when a headache starts, the pain is the precipitating factor, which does not have a strong correlation with PFO or a stroke risk. But when we look at migraines that do have an aura, this is a precipitating factor that could be blurred vision, it could be numbness. This could be, you know, seeing squiggly lines in your vision, which precedes the headache. And what we're looking for is to see, you know, do these patients have an aura or do they not have an aura. Patients with an aura, that can be a stroke mimic, but we also look at as a cause for migraines, could these patients have that PFO, which causes that change in blood flow and pressure, and it causes, you know, serotonin and other things in your body and in your bloodstream to go from the venous to the arterial side, which can cause that pain and cause that migraine

Host: Would you know if you had an aura?

Lindsay Goff, BSN, RN, NRP: Yes, most patients do. It's a pretty significant precipitating factor. And a lot of the patients that I see that, you know, are rule-out-strokes in the emergency room come in with these symptoms. So, it's acute onset of numbness. It could be blurred vision, it could be tingling in your fingers, it could be dizziness, it could be numbness on one side of your face or your body, And then the headache starts. So, that's what we're looking for.

Host: How does stroke fit into the conversation?

Lindsay Goff, BSN, RN, NRP: So, stroke fits into this conversation in two ways. The biggest way is that migraine with Aura is the biggest stroke mimic that we see nationally. So, we see posterior circulation strokes that have numbness with acute onset, with a headache, with dizziness, blurred vision, with light sensitivity. Is that a migraine or is that a stroke? But when we look at these patients that have ischemic strokes, PFO and migraines are one of the things we look at as risk factors.

Host: Lindsay, who should actually be concerned enough to ask a doctor about this.

Lindsay Goff, BSN, RN, NRP: So any patients that have a migraine or have a history of migraines with an aura. So, the precipitating factor of any numbness, also any patients that have a smoking history that are on any estrogen replacement therapy, any hormone replacement therapy, any other vascular risk factors. So, any peripheral vascular disease, any patient that has any risk factors for heart attack or stroke.

Host: Why is PFO often discussed after an unexplained stroke?

Lindsay Goff, BSN, RN, NRP: When patients come to us, whether their symptoms have completely resolved in a mini stroke event, a TIA, or if we do identify that these patients have, we call it a cryptogenic ischemic stroke, meaning stroke that was caused by a clot obstructing blood flow, but we don't know the cause. So, we look at two specific things. We look for paroxysmal AFib, so an irregular heart rate that comes and goes. If we don't find that, part of the workup is we're doing an echocardiogram with an agitated bubble study, which looks for that right to left shunting of blood flow or an air bubble in the heart, which indicates the patient is positive for a PFO.

Host: Wow. Can PFO closure help prevent another stroke in selected patients? And why isn't it routinely done just for migraine?

Lindsay Goff, BSN, RN, NRP: Yes. So, closure of PFOs is indicated for patients that are under 60 years of age, according to the AHA, closure of that PFO over 60, not in the setting of an ischemic stroke or in the setting of ischemic stroke, does say that the risk outweigh the benefit to close that procedure with surgery. There are other ways we can manage these patients with medical management, managing risk factors, modifying risk factors, and placing them on dual anti-platelet therapy.

Host: Lindsay, what would you like listeners to know if they live with migraines and they hear about this connection?

Lindsay Goff, BSN, RN, NRP: My message is my patients that have migraines and have had them their entire lives, if you notice any symptom with acute onset associated with your migraines, that is different, that does not feel like your migraines, please call 911 and come to the hospital immediately. This is the biggest stroke mimic, is a migraine with aura, but we have to rule out stroke because stroke can happen in young, healthy people, not just elderly patients that, you know, have other comorbidities.

Host: Why do some people start getting migraines later in life when they've never had them before?

Lindsay Goff, BSN, RN, NRP: So, it varies. We look at a variety of different things. So, we look at an anatomical cause for migraines, then we look at blood pressure. We look at stress causes. We look at their hydration status. But every single patient is different and every single patient has a different trigger for their migraines and a different cause. In neurology, not every single patient is the same. We can't do one set of testing to explain each patient's symptoms.

Host: In closing, is there anything else you'd like to add that maybe we didn't cover?

Lindsay Goff, BSN, RN, NRP: What I would love for the public to know is please, please, please see a doctor routinely so that we can look at these risk factors, such as PFOs, such as migraines with aura and their correlation with stroke. And you know those risk factors that can increase your risk. So, please see your doctor regularly, control your risk factors. And if you see any signs and symptoms with acute onset of stroke, please call 911 immediately.

Host: Well, thank you so much for sharing your expertise. This has been so informative and we really appreciate your time.

Lindsay Goff, BSN, RN, NRP: Thank you for having me. I truly appreciate it.

Maggie McKay (Host): Again, that's Lindsay Goff. Listen to more at umms.org/podcast, YouTube, or your favorite podcast platform. I'm Maggie McKay. Thank you for listening to Live Greater, a Health and Wellness podcast, brought to you by the University of Maryland Medical System. We look forward to you joining us again, and please share this on your social media.